Bladder exstrophy-epispadias complex: The effect of urotherapy on incontinence.

INTRODUCTION: Achieving urinary continence is a key goal in children born with the bladder exstrophy-epispadias complex (BEEC). Unfortunately, this goal is only moderately achieved despite sometimes extensive surgical treatment. Undergoing repeated hospitalization and operations may consequently have a negative impact on quality of life. We therefore believe that other, conservative treatment options should be explored in an earlier stage of incontinence treatment in BEEC patients. As part of this, an intensive urotherapy program based on was offered to patients with persistent incontinence after reconstructive surgery for BEEC. OBJECTIVE: The aim of this study is to evaluate the benefits of intensive urotherapy on incontinence after reconstructive surgery in children with BEEC. STUDY DESIGN: A retrospective chart study was performed including all children who were enrolled in an intensive urotherapy program because of persistent incontinence after reconstructive surgery for BEEC. Urotherapy consisted of a ten-day inpatient training program based on cognitive behavioral therapy, with intensive follow-up by experienced urotherapists. Main outcome measurement was continence, expressed as the percentage of children that achieved complete continence (good result; 100% dry) or 50-99% decrease of wet days a week (improved result) after treatment. RESULTS: Data of 33 patients with a mean age of 10.6 years were analyzed. In 61% of cases (20/33) an improved or good result was reported on incontinence after urotherapy. Children with classic bladder exstrophy more often achieved a good or improved result (13/16; 81%), compared to children with epispadias (6/16; 38%). The only patient with a cloacal exstrophy completed treatment with an improved result. From the group of patients with persistent incontinence, 75% (12/16) reported that the complaints were socially acceptable at the end of follow-up. DISCUSSION: By following our intensive urotherapy program the majority of patients achieved complete continence or improved incontinence. In addition, our results show that the inpatient training program has a positive impact on acceptance in cases of persistent incontinence. The urotherapists offer individualized care and clear guidance, which we deem essential elements of successful treatment. Considering that repeated surgery may impede progress and offers no guarantee of continence, we recommend giving preference to conservative treatment options. CONCLUSION: Our results show that 37% (12/33) of patients with BEEC who were enrolled in our intensive urotherapy program because of persistent incontinence after reconstructive surgery, achieved complete continence after urotherapy and 63% (21/33) still experienced some degree of incontinence. 75% of patients who did not achieve complete continence, described the remaining incontinence as socially acceptable. These findings strongly support counselling patients with BEEC to consider conservative treatment before opting for further surgery.

Elevating pediatric urology care: The crucial role of nursing research in quality improvement.

This educational article highlights the critical role of pediatric urology nursing research in improving the care of children with urological conditions. It discusses the multifaceted nature of pediatric urology nursing, addresses challenges such as limited nurse scientists and resource constraints, and highlights the need to overcome barriers to increase research involvement. The authors emphasize the importance of prioritizing research areas, the promotion of collaboration, and the provision of adequate funding and academic time for pediatric nurses to contribute to evidence-based practice, to improve patient outcomes. Furthermore, it highlights the importance of research in advancing nursing practice, shaping protocols, and advocating for the rights and needs of children with urological conditions and their families.

Dysfunctional Voiding: Exploring Disease Transition From Childhood to Adulthood.

OBJECTIVE: To improve our transitional care, we explored how childhood dysfunctional voiding (DV) develops into adulthood. DV is a common condition in both children and adults. However, the long-term course of childhood DV into adulthood is unknown and treatment over the ages differs. METHODS: A cross-sectional follow-up was performed in a cohort of 123 females treated from 2000 to 2003 for childhood DV with urinary tract infections (UTIs) and/or daytime urinary incontinence (DUI). The main outcome was a staccato or intermittent urinary flow pattern, possibly indicating persistent or recurred DV according to the International Continence Society criteria. Flow patterns of healthy women were used to compare results. RESULTS: Twenty-five patients participated in this study, with a mean duration of 20.8 years after urotherapy. In 10/25 (40%) cases, a staccato or interrupted urinary flow pattern was found on the current measurement, compared to 5/47 (10.6%) in the control group. Around 50% (5/10) of the patients with a dysfunctional flow pattern reported UTIs and 50% (5/10) experienced DUI. In the group with a normal flow pattern, 2/15 (13%) reported UTIs and 9/15 (60%) DUI. The impact of DUI on quality of life was moderate to high in both groups. CONCLUSION: Our results show that 40% of females who had extensive urotherapy for DV in childhood, still have DV according to International Continence Society criteria as an adult, 56% still experience DUI, and 28% UTIs. These data should be taken into account in the counseling of patients and for guiding the process of transition into adulthood.

Intravesical botulinum-A toxin in children with refractory non-neurogenic overactive bladder.

INTRODUCTION: Overactive bladder (OAB) with urinary incontinence poses a potentially significant impact on daily activities and quality of life. OAB can be unresponsive to specific urotherapy and antispasmodic medication. Due to its successful outcomes in the treatment of neurogenic bladder, intravesical botulinum-A toxin (BTX-A) became a possible solution for children refractory to treatment. OBJECTIVE: To analyse the outcomes of intravesical BTX-A injections on bladder volume and incontinence in children with refractory OAB. STUDY DESIGN: The charts of children diagnosed with refractory non-neurogenic OAB who underwent BTX-A treatment in our centre since 2011 were retrospectively analysed. The functional bladder volume (FBV) is expressed as a percentage of the expected bladder capacity (EBC) for age. Dependent variables were compared using the Wilcoxon Signed Rank test. A multivariate logistic regression was used to identify predictors of the response on urinary incontinence. RESULTS: Fifty children (41 boys) with a median age of 9.9 years were included. In the short term, there was a significant increase in FBV after initial BTX-A treatment from a median of 52.9%-70% (p = 0.000). In the short (<6 months) and long term (6-12 months) 72% and 46% showed improvement of continence, respectively. Male gender and small baseline FBV predict a positive outcome on continence in the long term. The most prevalent complications were urinary tract infections occurring in five cases (10%). DISCUSSION: Although BTX-A injections serve as an effective therapy to increase bladder volume in non-neurogenic OAB children, the outcomes on urinary incontinence are highly variable. This may be a consequence of the multifactorial aspects of this condition. BTX-A will enable children to inhibit their bladder urgency. The effectiveness of post-BTX-A urotherapy training will therefore most probably be higher. We believe that BTX-A injections should be reserved for children refractory to both specific urotherapy and medication. An appropriate population seems to be children with severe OAB symptoms, confirmed detrusor overactivity in urodynamic study and reduced bladder volume. CONCLUSION: In refractory OAB children, BTX-A injections are safe and effective in enlarging bladder volume and reducing OAB symptoms, particularly in the first six months after injection.

The effect of meatal correction on daytime urinary incontinence in girls with an anterior deflected urinary stream.

INTRODUCTION: Girls with an anterior deflected urinary stream (ADUS) are known to wet the toilet rim and their buttocks while voiding. This deviation may prevent adopting an ideal toileting position and can thus develop into a functional voiding disorder. Although surgical correction of the urinary stream by a meatotomy is part of standard care in girls with ADUS and lower urinary tract symptoms (LUTS) at our center, little is known about the effect of this procedure on daytime urinary incontinence (DUI). OBJECTIVE: To assess the effect of meatal correction on incontinence in girls with ADUS and DUI, and to find predictors for therapy success. STUDY DESIGN: A retrospective chart study including all girls with ADUS and DUI who underwent a dorsally directed meatal correction at our tertiary referral center between 2005 and 2018 (n = 274). The main outcome measurement was continence according to the International Children's Continence Society criteria, expressed as the percentage of children that were continent at post-surgical follow-up (complete response). Multivariate logistic regression was used to identify predictors of continence. RESULTS: In 93% of girls, the direction of the urinary stream was no longer anterior deflected. 29% (n=79) of all girls were continent at post-surgical follow-up. We could not find a convincing predicting factor for achieving continence. DISCUSSION: Although meatal correction is successful on normalizing the direction of the urinary stream, less than one-third of girls became continent. In addition, we were unable to indicate which girls will profit from this procedure in terms of continence. Since not every girl with ADUS develops incontinence complaints, it may also be questionable whether ADUS and incontinence are directly related. Since other, less invasive and more effective treatment options for DUI are available, meatal correction should therefore be considered a last-resort option in the treatment of pediatric DUI in girls with ADUS. CONCLUSION: Of the 274 girls with ADUS and DUI, 29% did benefit from a meatotomy. No convincing indicator for therapy success could however be found. Therefore, we discourage a meatotomy as standard treatment in girls with ADUS and DUI.

Pelvic floor rehabilitation in children with functional LUTD: does it improve outcome?

INTRODUCTION: If children do not experience satisfactory relief of lower urinary tract dysfunction (LUTD) complaints after standard urotherapy is provided, other treatment options need to be explored. To date, little is known about the clinical value of pelvic floor rehabilitation in the treatment of functional voiding disorders. OBJECTIVE: Therefore, we compared pelvic floor rehabilitation by biofeedback with anal balloon expulsion (BABE) to intensive urotherapy in the treatment of children with inadequate pelvic floor control and functional LUTD. STUDY DESIGN: A retrospective chart study was conducted on children with functional incontinence and inadequate pelvic floor control. All children referred for both intensive inpatient urotherapy and pelvic floor rehabilitation between 2010 and 2018 were considered for inclusion. A total of 52 patients were eligible with 25 children in the group who received BABE before inpatient urotherapy, and 27 children in the group who received BABE subsequently to urotherapy. Main outcome measurement was treatment success according to International Children's Continence Society criteria measured after treatment rounds and follow-up. RESULTS: Baseline characteristics demonstrate no major differences between the BABE and control group. There was a significant difference in improvement between BABE and inpatient urotherapy after the first and second round of treatment (round 1: BABE vs urotherapy; 12% vs 70%, respectively, round 2: urotherapy vs BABE; 92% vs 34%, respectively, both P < .001). In both cases, the urotherapy group obtained greater results (Fig. 1). When the additional effect of BABE on urotherapy treatment is assessed, no significant difference is found (P = .355) in the children who received BABE; 30 (58%) showed improvement on pelvic floor control. DISCUSSION: Our findings imply that training pelvic floor control in combination with inpatient urotherapy does not influence treatment effectiveness on incontinence. Intensive urotherapy contains biofeedback by real-time uroflowmetry; children receive direct feedback on their voiding behaviour. Attention offered to the child and achieving cognitive maturity with corresponding behaviour is of paramount importance. It is known that combining several kinds of biofeedback does not enhance the outcome. However, our results do not provide a conclusive answer to the effectiveness of pelvic floor physical therapy in the treatment of children with LUTD because we specifically investigated BABE. CONCLUSION: In this study, we could not prove that pelvic floor rehabilitation by BABE has an additional effect on inpatient urotherapy on incontinence outcomes. Considering the invasive nature of BABE, the use of BABE to obtain continence should therefore be discouraged.

Daytime urinary incontinence in children and adolescents.

Daytime urinary incontinence is common in the paediatric population and affects approximately 7-10% of children (aged 5-13 years). Several subtypes of daytime incontinence, which are classified according to their relation to the storage and voiding phases of bladder function, exist. Risk factors for these subtypes of incontinence can be genetic, demographic, environmental, behavioural, or physical. Therefore, treatment is multidisciplinary and needs an adequate diagnosis to be successful. Urotherapy is the first-line treatment for all types of daytime incontinence. It can be defined as bladder re-education or rehabilitation, aiming at correcting the filling and voiding function of the bladder-sphincter unit. Comorbid problems, such as constipation, urinary tract infections, and behavioural problems should also be treated during urotherapy. For comorbidities and severe bladder overactivity, medication might be necessary. Although usually effective, treatment of daytime urinary incontinence in children is often complex and requires patience. Nonetheless, patients and parents are usually motivated for urotherapy, since quality of life is severely reduced in in children with incontinence.

Open and Laparoscopic Colposuspension in Girls with Refractory Urinary Incontinence.

INTRODUCTION: Lower urinary tract symptoms (LUTS) are very common in children. Standard treatments consist of urotherapy, antibiotic prophylaxis, anti-muscarinics, physical therapy, and the treatment of coexisting constipation. A small group of girls also present with stress incontinence or with stress-induced urge incontinence. In cases of persistent LUTS due to congenital bladder neck insufficiency (BNI), surgical treatment might be considered. The aim of this paper is to assess the results of open and laparoscopic colposuspension in children with refractory urinary incontinence (UI). MATERIALS AND METHODS: The results of 18 open and 18 laparoscopic consecutive colposuspensions were analyzed. All patients had UI and failed conservative treatment. BNI was proven by repeated perineal ultrasound and video-urodynamic study. The laparoscopic procedure was performed preperitoneally and the open procedure was via a transverse lower abdominal incision. The same postoperative protocol was used in both groups. RESULTS: The mean operation time was 65 min for the open and 90 min for the lap procedure (p < 0.05). Full success was achieved in 7/18 in the open and in 8/18 in the lap group and partial response was seen in 3/18 and in 5/18, respectively (p = 0.64). No intraoperative complications occurred in this cohort. CONCLUSION: Open and laparoscopic colposuspension can be used to treat refractory UI in children with BNI when non-invasive methods fail.